Mothers, Babies, Midwiives: With Woman in Kathmandu

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I received an email from Kiran, the President of the Midwifery Society of Nepal.

In part it said: “The Midwifery Society had an emergency meeting to help women and children….. [we have set up]..a mobile camp for the care of women and newborns, infection control, food, toilets and hand hygeine including distribution of clothes….. I will share our activities with you…. Women and children are deprived of basic needs…… It is good if you are like minded to help those who really need it….”

Nepal, like many poor countries, is a country where women do not yet expect the treatment that we consider to be our right. Part of my goal in Nepal was to support the practice of the midwifery model of care both at the birth center and wherever midwives work. The midwifery model of care at its heart is about “Listen to women” (the motto of the American College of Nurse Midwives). How can this be activated among women who live in a culture where privacy is not highly valued, where consent for care is not standard, where respect for professionals seems sometimes to be greater than self respect for women?

I struggled in the Kathmandu Birth Center, to encourage care to take place in a closed private room, but often it took place in a corridor-like triage area with a curtained bed but both doors open and people walking through. This was persistent even though there were great private rooms elsewhere in the building.

If I was present for an intimate aspect of care, a vaginal exam for instance, I did not know the women personally and did not speak her language, so I always asked to be introduced and permission requested for my presence. The midwives found this not just amusing but weird and uncomfortable. It seemed that a white woman like a doctor, particularly a male, had assumed rights, and I was violating norms by suggesting acting differently.

Are violations of norms always unacceptable? What about norms like these, based on hierarchies which deny women self-respect and dignity? I believe these midwifery values to be absolutes and prerequisites for appropriate care. Can we share those values, as outsiders, now, in Nepal?

A couple of days before I left Nepal, Kiran and I sat side by side on the floor in her house with our computers on our laps, our stomachs full of Dal Bhat, and our heads full of planning for the anti-shock garment pilot project. We wrote a planning document together, a couple of middle aged midwives from distant cultures connecting over a plan and a commitment to make it happen. It was a fulfilling evening.

The next day I went to see Dr Regmi at the Ministry of Health to give her the garment I had with me and to update her on our progress. She welcomed me into the office in the middle of her meeting, and requested an immediate demonstration to the staff. Within 5 minutes of my walking into the room there were 20 Nepali civil servants gathered around. Dr Regmi volunteered to be the patient. I appreciated her enthusiasm but rejected the offer as the NASG and a sari is not a modest combination. We did the demonstration on the floor of her office at the Ministry of Health to the delight of all and with many interested questions. It was a fantastic and inspiring piece of bureacratic informality.

The next day I left. At the airport I met Surya Bhatta who works for One Heart Worldwide which has been working on a pilot program for the anti-shock garment in a rural area. He was on his way to India to pick up some anti-shock garments. Sometimes coincidence is too weird to be believable.

A month later, and back in my Dallas life and midwifery work, those three meetings resonate powerfully in me and give me the momentum and energy to move forward with With Woman in Kathmandu, to make the project happen and to return to Nepal This is my promise.

The staff meeting was to begin at 1:30. At 2pm people were beginning to gather. There seemed to be no agenda but we began. Everybody chatted and the agenda made itself apparent. Chapatis and spicey potatoes and cups of tea were brought in. People wandered in and out and at one point I thought I’d better give my prepared report on my visit. So I did. I wanted to avoid being rude and inappropriate, but the more I suggested the more they nudged me to be more direct. The staff received everything I said with such receptive kindness that it was humbling. Truly amazing how different behavior can be in another culture, and yet we really do understand and respect each other. There is something about the way things work here that is both frustrating and extremely refreshing at the same time. I will miss it. The slow pace is both pleasant and irritating by turns. Nothing happens and things surprise you and all of a sudden, it’s done. Birth can be like that too, can’t it?

I had my Dal Bhatt this evening, with the realization that I won’t be eating it many times more. I rode the bus on my 15 cent ride through the dirty streets knowing I would soon be breathing the marginally less polluted air of Texas. I walked through the throngs of pedestrians, narrowly missed by hooting motor bikers, knowing how much I would miss the street life, the noise and variety of Kathmandu in suburban Dallas.

Women are women, midwives are midwives, and birth is birth, but Nepali style it’s all a bit different, wonderfully so. Thank you Kathmandu. And lots of love.

The sun rose to another clear day and a clear view of the mountains the day after the elections. What would happen next? After breakfast, I got organized to head out to the birth center. Everything was…. normal. How interesting. No violence, no excitement, just life, busy streets and newspaper headlines that the elections were peaceful. Results were coming in. Record voter turnout. The maoists who led the stirkes had lost badly. But rather than responding violently to defeat, it seems they were licking their wounds and moving on. The marxist-leninists and the Nepali Congress are the 2 big winners with the vast majority of votes. The maoists, with a smaller number, hold the balance of power. Other parties have mostly 5% or less. All of this seems such a mature democratic outcome and brings a dose of optimism and confidence in the future that I think is in the air.

With the birth room redecorated, the childbirth education in place and the brochure at the printers, my work here is coming to a close.The anti-shock garment project sent me in and out of offices, NGO and Government, and I did two hospital presentations on its use.The new graduate level program in midwifery will hopefully start next year, It will be the first in the country and a prerequisite for the Midwifery Society of Nepal to have membership in the International Confederation of Midwives which regulates the profession worldwide. An initial research project would raise the prestige of the program and of the profession. It may really happen that it will be an anti-shock garment project. Kiran is for it. Dr Regmi, a big cheese at the Ministry of Health is for it and will fund impementation if initial funding is found. Doesn’t that sound like concrete progress? It feels good.

Meanwhile there was a funny day last week when the world seemed to be converging on APS birth center.Volunteers and staff were hauling around dusty piles of medical equipment, sorting, chucking, organizing. That frenzied, excitable mood that happens with a big clean was all around. Some of the senior staff who come in occasionally, Rashmi, Asha, Amala, were all there. And so were the Duggars! What? Yes father Duggar and Jill Duggar from the reality TV show about the family with the 19 biological children along with TV crew, invaded the festive cleaning up atmosphere of the center. For my non-US readers, know that even if, like me, you are barely aware of television and popular culture, you cannot help hearing about the Duggars and their TV tribe in the US. Jill D is on her way to becoming a midwife and while visiting Nepal, she wanted to visit a birth center, Nepali midwives and make an episode about her aspirations. Rashmi was interviewed. Mothers, babies and midwives were filmed. A festive mood prevailed.

While this was going on, the normal day at the center was happening too. A couple came in, for what they thought was an intial prenatal appointment at 29 weeks pregnant. But no heart-beat, and measuring many weeks smaller than 29 weeks. Sadly her baby was not alive. The couple were hugged and supported. Follow-up care was arranged. They had a a quiet corner of the center as the camera crew charged around. Sometimes events coincide in strange ways. Meanings are unclear but the strangeness implies meaning of some kind. That is midwifery in Nepal and everywhere.

Birth center chugging along. Feeling that my work there is finishing off projects: making sure the brochure is printed, getting new towel rails by the sinks (goal to encourage handwashing), discussing with Rashmi the placement of the new Ganesh statue. But my focus the last couple of weeks has been more outward and a bit outside my comfort zone: the anti-shock garment, hospitals, doctors, NGOs and Government administrators. Very different.

My first foray into the hospital world was a low key effort: Did a class for nursing students and faculty at at Tribhuvan University. It was a lot of fun. They were warm and enthusiastic. Here are some of the students having fun with practising labor support.

practising labor support

Tea with faculty afterwards

You may remember, that thanks to last minute donors I was able to bring a supercool neoprene and velcro device for stabilizing women who are in shock secondary to postpartum hemorrhage. Very enthusiastic about this simple thing that has been endorsed by the World Health Organization, has great outcomes in clinical trials but is virtually not used here in Nepal, where postpartum hemorrhage remains the number one cause of maternal mortality. So I put together a presentation on the device together with a bit of hands on training, and have been talking, telephoning, emailing, knocking on doors to spread the word. I have met some interesting people this way, and experienced lunch on the roof of the United Nations Fund for Population and a chauffered drive in a Government vehicle in which we drove through the middle of a preelection demonstration in Durbar Square. I did manage a presentation on the anti-shock garment at one of the hospitals, but whether I can really get a structure in place that will lead to training in use of the device, and incorporation into clinical practice is another matter.

Meanwhile, the elections took place yesterday and seem to have been largely peaceful with higher turnout than expected. The day was yet another holiday. This time the shut-down was total; a festive atmosphere of families wandering in the streets. Kiran, president of Midwifery Society of Nepal, invited me to lunch at her house where we talked for four hours…. all midwifery. went on the roof of her house to stare at the mountains through Russian communist era binoculars decorated with hammer and sickle. Ate dal bhat of course. Lots of tea of course.

Love the food here. Great for vegetarians. Again, the influence of both India and Tibet but independently Nepali. Nepalis have a very light breakfast: a cup of tea perhaps and maybe a piece of fruit or something very small to go with it. Loads of types of tea. The classic is Masala milk tea. I don’t like it much. Also lots of plain back tea (usually sweetened) (Drinking some now as I write, of course). Also, jasmine tea, mint tea and lots more. I love hot lemon with honey… basic and good. Around 10:30 or 11, the Nepalis break for brunch, which is Dal Bhat, litereally a plate of lentil soup and rice, but can be so much more, with added curries and vegetables and chutneys and maybe meat and even yogurt. Then, early afternoon, time for a snack. This “roti” could be a bit of anything but that’s when I have my small cup of bean soup with a piping hot chapti or two. A unique Nepali snack is momos: vegetable or meat dumpings, steamed or fried with a spicey dipping sauce. Dinner is…. Dal Bhat again…. and while this sounds boringly repetetive, dal bhat does have a lot of variation to it. Pretty healthy way to live. And for me, tasty too. Indian options are lots of curries and tandoori, while Tibet has its own cuisine with heavy breads and soups such as Thukpa. Then to add a bit of interest, many ethnic groups in Nepal have their own cuisines. Newaris have some widely eaten dishes. The only one I have taseted is the “pizza” called chatamari.

Dal Bhatt, fancy version: lentila soup, veggie curry, garlic spinach

Dal Bhat fancy version mixxing it up with yogurt

“Roti” bean soup with chapati from the dive next to the birth center. Note puffy chapti hot off the fire.